Alex Scott-Samuel is senior lecturer in the Department of Public Health in Liverpool University where he has worked since1994. He came to Liverpool in 1966 as a medical student, going on to train in public health in the early seventies.
He worked in the NHS with, what was then Liverpool Health Authority, what is now the Primary Care Trust and he was a consultant there for sixteen years from 1978-94. Alex is interested in community development, in arts, and the overlap between the arts and health and in poetry. He organises the Liverpool Socialist Choir; he loves singing. He’s also very passionate about Bob Dylan. He talked to Nerve about inequality, health and privatisation of health services.

Inequalities of Health

My official job is teaching and research. I teach post-graduates on our masters course in public health and I do research around health inequalities; in other words things like poverty and health, housing and health, stuff to do with health policy.
Public health is a branch of medicine. It’s the only one that deals with populations rather than individuals.
I’ve been interested in this area since the mid-seventies and as you can imagine there is an enormous amount of relevance to that in Liverpool.

There are a lot of things I am involved with that I can’t do within my official job description such as voluntary organisations. I’m joint chair of the Politics of Health Group, which is concerned with the overlap between health and politics. We are publishing on-line, a major report called UK Heath Watch, which is an alternative report on the state of health in the UK to co-inside with the big government health inequalities summit conference that they are having as part of the EU Presidency. We are bringing it out on the same day the 17 October. I’ve been involved with the Pioneer Health Foundation for about fifteen years. This group consists of the survivors of the original Peckham Health Centre, which existed, in Peckham, between 1935 and 1950. It was the first, what would be called nowadays, Healthy Living Centre. In other words this is about promoting positive health, not just about preventing disease etc. It was a fantastic project, and the sort of thing that would be ahead of what’s going on now, if it still existed. But the new health service of 1948 didn’t understand it and wouldn’t fund it so it folded. But the people involved have been keeping the ideas alive ever since. I’m involved in other activities, some of them political; I’m a member of the Labour Party, although I despair at the current government and its health policies. I’m also very much involved in the Politics of Health Group, and the Keep Our NHS Public Campaign, which was launched during the Labour Party Conference.

What is your opinion of the recent Government report on inequality and health, saying that the biggest indicator of ill health is still poverty; that there is a direct correlation between the two?
My view is that however much the government talks about health inequalities, and they do talk about it a lot, and however many policies they have around health inequalities, and they do have a lot of policies, and I fully acknowledge that. As long as their action and their policies are what I would call ‘down-stream’, in other words things that focus on the NHS and diseases and so on, rather than the up-stream factors; the original factors that cause the inequality in the first place things like poverty and macro-economic policies, patriarchy and gender inequalities etc.; unless they actually deal with these fundamental issues; trade policy and so on; and, of course this government is very much driven by what is generally called neo-liberal market oriented policies; as long as those things are happening in the background then the health inequalities are going to continue, however many superficial individualistic policies there are for dealing with health inequalities.
When Labour came to power in 1997 they were very keen to take action against health inequalities. But unfortunately, after the first couple of years, Frank Dobson and Tessa Jowell, who were the Health Secretary and the Public Health Minister, moved on, or were replaced. This was around the time that Labour, very noticeably, moved to the right (although I suspect it had been happening all along to some extent), and increasingly came to resemble the conservative government before it and Margaret Thatcher before that, and, of course, became closely allied with the US and Bush’s policies.
People started getting interested in health inequalities in the seventies and particularly after the Black Report in the eighties. This was commissioned by the Labour Government in ’78, but by the time it reported in 1980 Thatcher was in power and didn’t want to know about inequalities. There was a recent conference celebrating 25 years since the Black Report. That was in September, in Manchester. Then this report came out in August from a group sponsored by the government headed up by Michael Marmot, from University London which basically showed that on the two headline indicators that the government has on health inequality which are life expectancy inequalities and infant mortality inequalities, for both of those, for the first six years of the Labour Government – 1997-2003 – inequalities had not only not got better, they were actually continuing to get worse and that’s because the up-stream policies that drive inequality are still acting in a way that will increase those inequalities. For example income inequality, which I think is much more important to health inequality than the kind of NHS health promotion type policies the government has been introducing, in the name of inequality. Economic inequality continued throughout the first six years of this government as it was in the mid 1980s, at the height of Thatcherism.
It is only when thing like economic inequalities start coming down and they start really cutting poverty (I know there have been reductions in poverty, but nothing like the targets that the government set itself, and those were relatively modest), until it starts doing serious things in those areas inequalities won’t reduce. Having said that, I don’t expect them to change their policies in those areas because they’re very tied to those kinds of approaches. The bottom line for me is that the whole capitalist economic system, that the government is part of, and that any likely future government is part of is so fundamentally rooted in inequality; capitalism is an unequal system and it can’t be otherwise, it’s unequal by definition. The inequality is between those who produce the wealth and those who get it. Without any changes in that sort of system inequalities are not going to reduce and the other key driver that I mentioned is patriarchy, and there is a lot of evidence; firstly I think it’s absolute rubbish for people to suggest that we live in a post-feminist era and that there are equal opportunities. Things aren’t as bad as when I was growing up in the fifties and sixties, but there is still enormous gender inequality and that so many of the things that drive gender inequality, including the factors that I mentioned are driven by excessive masculine gender roles. In other words things like excessive risk taking, aggression, violence, suppression of emotions etc. etc. And because that is as common in the cabinet room as it is in the public bar there is no likelihood whatsoever that the government will do anything about that either. So that in a nutshell is my take on inequality.

Alyson Pollack in her book NHS Plc describes privatisation in the NHS and how it has accelerated. Under the Social Health and Care Act 2003 the Primary Care Trusts can contract out all aspects of primary medical services and there are other areas, which are going over to the private sector. How do you think that people should handle this ‘steam roller’ to privatisation?
I’m absolutely appalled by what’s been going on, in terms of the government encouraging private sector involvement in the NHS. It goes back to the 1980s when the Thatcher government privatised, so called, ancillary services in the hospitals, things like cleaning, and catering, and portering, and laundry services. At that time it was very obvious that this was bad news for the workers concerned because often the same people were re-employed by private organisations with much worse terms and conditions, they had to work much harder for the same wages. The quality of the work suffered and we are now seeing the outcomes of all that in terms of hospital infection rates and there has been a lot of outbreaks of hospital infection recently that have been linked to the quality of cleaning. People, like cleaning staff for example, were part of the caring team, in a sort of unofficial way, because obviously people in hospital talk more to nurses than doctors and talk more to cleaners than nurses. So that kind of function went completely by-the-board.
I was one of many people who waited a long time for Labour to get back into government and I was horribly disappointed after Alan Milburn became Health Secretary. Originally there was a concordat signed with the private sector about the beginnings of their involvement in the NHS. And then increasingly, not just ancillary services, but actual clinical services; services involving patients, started getting privatised, most obviously elective surgery, in other words none emergency surgery.
I would acknowledge that there are arguments, I don’t share them, for a limited involvement of private sector facilities in terms of reducing waiting lists and so on. In other words renting or borrowing services from the private sector in order to deal with patients on waiting lists rapidly, but once that’s done that should be the end of it. What New Labour did was increasingly involve the private sector in the provision of NHS services and through such things like the independent treatment centres that they set up in the last couple of years, there’s now a wide-spread private involvement in NHS services and by the end of this year people getting elective surgery are going to be offered the choice of five locations at least two of which have to be private sector. So Labour are very actively forcing private sector services into the NHS. They are creating an open market in services, which is going to have a lot of negative effects. It’s going to mean that some hospital services will fail to meet the competition and literally go out of business. We don’t know to what extent that is likely to happen, but it’s one possibility and the Labour Government acknowledge that it’s a possibility.
In addition there’s going to be an enormous amount of money wasted, because obviously, as with hospitals built with the Private Finance Initiative [PFI] where money is borrowed from the private sector, taxpayers money is going to go into the pockets of shareholders, whether it’s PFI builders and hospital developers, or whether it’s the new companies that are going to be providing private surgical and other services on the NHS. So additional money has to be paid to those companies in order that they make a profit and those are funds that could be used in developing NHS services. I don’t claim for a minute that NHS services are perfect or that there aren’t a lot of problems with them, but as I said twenty years ago about British Rail, if something in the public sector is not working well, the answer is to use management and other approaches to make it work better, not to privatise it.
There is absolutely no reason at all to think that the NHS will benefit from this market that Labour have created. If you look at this service in the US, where Labour seem to have got all their ideas from, it is absolutely horrendous the market there. They have a vast amount of wastage on transaction costs and duplication of services and so on, and a large number of people are not dealt with the private services because the tend to deal with the simpler conditions like elective surgery rather than the more difficult conditions like emergency which will continue to be dealt with in NHS hospitals; and incidentally make it harder for those NHS hospitals to compete because it takes more resources to deal with more difficult and more complex cases and emergency cases, than it does with the kind that the private sector are dealing with.

So if you and other professionals have told the government and they know that these things are not going to work properly, then why do they continue on down that road?
Well, basically it’s because practically all government ministers will do Tony Blair’s bidding and Tony Blair and those ‘hand picked’ people that support him in the Number 10 policy unit are obsessed with the US market model and obsessed with the belief that the private sector is always better than the public sector, and that the public sector is a drain on the economy. As long as Blair pushes that line his ministers, if they want to remain as ministers, are more or less forced to go along with it. I think some of them do it more readily than others. But I would predict that when Gordon Brown takes over from Blair that they will suddenly rediscover - I wouldn’t say socialist - their more left wing roots and not be as wedded to the market as they are at the moment. Patricia Hewitt, for example, the current health secretary, was a supporter of Tony Benn in the ‘70s and in the 80s was very strong on civil liberties and social justice. Her conversion to the free market, I think, is relatively recent. In the mid-90s she was working on the Commission for Social Justice. I don’t know if she is somebody who will revert to the left in the future, but certainly because the Prime Minister is so far to the right that explains why current government policy is and why his cabinet is.
The latest thing is that Labour are now going to be privatising primary health care services, like general practice services and community nursing services and so on. A really dreadful circular came out recently from the government, which basically has been widely criticised by just about everybody concerned, even the NHS managers, who are normally loyal to the current government, because it is just so incoherent and absurd what is being proposed, which is that primary care services, instead of being comprehensive and well planned should be just provided by any kind of motley collection private or voluntary service providers who can successfully bid for them. The Primary Care Trusts, which currently employ community nurses and many other community staff will be prevented from doing so in future; it’s just a complete disaster and just the most appalling betrayal of people who thought that the Labour Party stood for a high quality, universal, comprehensive health service.

What Blair would say is that there is no alternative. He stated at the Labour Party conference that it would be like questioning why autumn follows summer; that the free market has to come in. We’ve got to compete on the world stage and we’ve got to keep public spending down because we need to meet targets that the World Bank have set.
Well there are very successful social democracies, and I wouldn’t call the Labour Party under Blair a social democratic party, I would now call it Christian democratic, in other words a very right wing kind of party. There are successful social democracies the most obvious being Norway and Sweden, which are part of the capitalist world, but have very successfully, followed egalitarian social democratic principles. There is absolutely no reason at all why the UK shouldn’t do the same. Compass, the Labour Party think tank recently published a pamphlet on Swedish social democracy and the possibilities for the UK to follow that route. While I accept entirely that in my lifetime we are likely to remain with a capitalist model, I would very much push for a genuine social democratic model with a genuine welfare state, and there is no reason at all why we shouldn’t follow that. An enormous amount of money could be transferred from expenditure on such things as defence, which are unimportant in the countries I have mentioned and in countries such as Switzerland and transferred to welfare.

So what can ordinary people, the people in the street, do about this move to privatisation?
Well, there is a new movement launched during the time of the Labour Party conference called Keep Our NHS Public and I’m hoping that will become a real mass movement and, in the same way that has happened in other areas: the environment for example, that the mass of the people will start demonstrating that they don’t go along with these government policies. I’m hoping that there will be a strong local organisation in Liverpool, as in other areas of the country and that people will actually be able to show what they feel about this in a way that might actually cause the government to think again. The website is: www.keepournhspublic.com and I’m hoping that people will engage with this movement and whenever there are consultations about change within the NHS, and the government is going to have to consult about the kind of changes we’ve been discussing, I’m hoping people will express their views and to tell the government that they don’t want the government to follow the path that they are following.
This government claims to value people, but it fails to behave in a way that suggests that it really does value people. I want to once again live in a country that really does value people and I want the taxation that I pay to be spent on welfare not on war and conflict and defence.

How do you think that, coming from the perspective of the readers of Nerve magazine, which is basically about arts and culture, people can get involved in this campaign? Do you think that art has a role to play?
Yes I do. I think the overlap between arts and health is something that people are becoming increasingly aware of in a general sense. People are seeing what arts have to offer the health sector and health promotion and so on. And I’m hoping that artist will increasingly express their views about what is happening in the health sector through their work as well as outside of it. I say as well as outside of it because, for example the launch statement of Keep our NHS Public has been signed by a lot of writers and other people involved in the arts. I’m hoping that people will move from expressing art in that way to actually using art to express their views about what goes on. I haven’t thought that through enough to know how that might happen, but certainly there have been social movements in other countries that have involved the use of graffiti and the de-facing of hoardings - like, most obviously, tobacco hoardings. It might be useful to see that some of that kind of art in relation to promoting a publicly owned NHS.